Nokea
Which of the following actions should the nurse take when assessing a patient with trigeminal neuralgia?
- A. Examine the mouth and teeth thoroughly.
- B. Have the patient clench and relax the jaw and eyes.
- C. Identify trigger zones by lightly touching the affected side.
- D. Gently palpate the face to compare skin temperature bilaterally.
Correct Answer: A
Rationale: Oral hygiene is frequently neglected because of fear of triggering facial pain. Having the patient clench the facial muscles will not be useful because the sensory branches of the nerve are affected by trigeminal neuralgia. Light touch and palpation may be triggers for pain and should be avoided.
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The nurse is caring for a patient who had a C8 spinal cord injury 10 days ago and has a weak cough effort and loose-sounding secretions. Which of the following actions should the nurse implement initially?
- A. Suction the patient's oral and pharyngeal airway.
- B. Administer oxygen at 7-9 L/minute with a face mask.
- C. Place the hands just below the xiphoid process and push upward when the patient coughs.
- D. Encourage the patient to use an incentive spirometer every 2 hours during the day.
Correct Answer: C
Rationale: Since the cough effort is poor, the initial action should be to use assisted coughing techniques to improve the ability to mobilize secretions. The nurse places the heels of both hands just below the patient's xiphoid process and exerts firm upward pressure to the area, timed with the patient's efforts to cough. Administration of oxygen will improve oxygenation, but the data do not indicate hypoxemia. The use of the spirometer may improve respiratory status, but the patient's ability to take deep breaths is limited by the loss of intercostal muscle function. Suctioning may be needed if the patient is unable to expel secretions by coughing but should not be the nurse's first action.
The nurse is admitting a patient with a spinal cord injury. Which of the following collaborative and nursing actions should the nurse do immediately? (Select all that apply.)
- A. Stabilize spine with sand bags
- B. Nasogastric (NG) tube feeding
- C. Ensure patency of airway
- D. Avoidance of cool room temperature
- E. Insert Foley catheter
Correct Answer: A,C,E
Rationale: Immediate care for a patient with a spinal cord injury is to ensure a patent airway, stabilize the spine with a hard collar or sand bags, and insert a Foley catheter. Avoidance of a cool room temperature is not part of immediate care. A tube feeding would not be initiated in the immediate postinjury care period.
The nurse is caring for a patient with Bell's palsy who refuses to eat while others are present because of embarrassment about drooling. Which of the following responses is best for the nurse to do?
- A. Respect the patient's desire and arrange for privacy at mealtimes.
- B. Teach the patient to chew food on the unaffected side of the mouth.
- C. Offer the patient liquid nutritional supplements at frequent intervals.
- D. Discuss the patient's concerns with visitors who arrive at mealtimes.
Correct Answer: A
Rationale: The patient's desire for privacy should be respected to encourage adequate nutrition and reduce patient embarrassment. Liquid supplements will reduce the patient's enjoyment of the taste of food. It would be inappropriate for the nurse to discuss the patient's embarrassment with visitors unless the patient wishes to share this information. Chewing on the unaffected side of the mouth will enhance nutrition and enjoyment of food but will not decrease the drooling.
The nurse is caring for a patient with a neck fracture at the C5 level in the intensive care unit. During initial assessment of the patient, the nurse recognizes the presence of neurogenic shock upon assessing which of the following findings?
- A. Hypotension, bradycardia, and warm extremities
- B. Involuntary, spastic movements of the arms and legs
- C. Hyperactive reflex activity below the level of the injury
- D. Lack of movement or sensation below the level of the injury
Correct Answer: A
Rationale: Neurogenic shock is characterized by hypotension, bradycardia, and vasodilation leading to warm skin temperature. Spasticity and hyperactive reflexes do not occur at this stage of spinal cord injury. Lack of movement or sensation indicates spinal cord injury, but not neurogenic shock.
The nurse is caring for a patient who sustained a spinal cord injury a week ago and becomes angry, telling the nurse 'I want to be transferred to a hospital where the nurses know what they are doing!' Which of the following actions by the nurse is best?
- A. Ask for the patient's input into the plan for care.
- B. Clarify that abusive behaviour will not be tolerated.
- C. Reassure the patient about the competence of the nursing staff.
- D. Continue to perform care without responding to the patient's comments.
Correct Answer: A
Rationale: The patient is demonstrating behaviours consistent with the anger phase of the mourning process, and the nurse should allow expression of anger and seek the patient's input into care. Expression of anger is appropriate at this stage and should be tolerated by the nurse. Reassurance about the competency of the staff will not be helpful in responding to the patient's anger. Ignoring the patient's comments will increase the patient's anger and sense of helplessness.